2 Living Donor Registration Form.xlsx

			Living Donor Registration (LDR)
			Fields to be completed by members
			Form Section	Field Label	Notes
			1-Provider Information	Recipient Center Name	Display Only
			1-Provider Information	Center Code Type	Display Only - Cascades from Database
			1-Provider Information	Center Code	Display Only - Cascades from Database
			2-Donor Information	Donor Last Name	Display Only - Cascades from Database
			2-Donor Information	Donor First Name	Display Only - Cascades from Database
			2-Donor Information	UNOS Donor ID #	Display Only - Cascades from feedback
			2-Donor Information	Home Address
			2-Donor Information	Home City
			2-Donor Information	Home State
			2-Donor Information	Home Zip
			2-Donor Information	Home Phone
			2-Donor Information	Work Phone	Not required
			2-Donor Information	Email	Not required
			2-Donor Information	Donor SSN
			2-Donor Information	Donor Date of Birth
			2-Donor Information	Donor Gender//Gender
			2-Donor Information	Marital Status at Time of Donation
			2-Donor Information	ABO Blood Group	Display Only - Cascades from Database
			2-Donor Information	Living Donor Type
			2-Donor Information	Living Donor Type Other Specify
			2-Donor Information	Ethnicity/Race
			2-Donor Information	Citizenship
			2-Donor Information	Year of Entry into U.S.
			2-Donor Information	Country of Permanent Residence
			2-Donor Information	Highest Education Level
			2-Donor Information	Did the donor have health insurance
			2-Donor Information	Functional Status
			2-Donor Information	Physical Capacity: (check one)
			2-Donor Information	Working for Income
			2-Donor Information	Working for Income//If No, Not Working Due To: (check one)
			2-Donor Information	Working for Income//If Yes
			2-Donor Information	% Macro vesicular fat
			2-Donor Information	% Micro vesicular fat
			3-Pre-Donation Clinical Information	Viral Detection://Have any of the following viruses ever been tested for: HIV, CMV, HBV, HCV, EBV
			3-Pre-Donation Clinical Information	HIV Status
			3-Pre-Donation Clinical Information	CMV Total	Not required
			3-Pre-Donation Clinical Information	CMV//IgG
			3-Pre-Donation Clinical Information	CMV//IgM
			3-Pre-Donation Clinical Information	CMV//Nucleic Acid Testing	Not required
			3-Pre-Donation Clinical Information	HBV
			3-Pre-Donation Clinical Information	HBV//Core Antibody
			3-Pre-Donation Clinical Information	HBV//Surface Antigen
			3-Pre-Donation Clinical Information	HBV//HBV/DNA (NAT/PCR)
			3-Pre-Donation Clinical Information	HCV
			3-Pre-Donation Clinical Information	HCV//Antibody
			3-Pre-Donation Clinical Information	HCV//RIBA
			3-Pre-Donation Clinical Information	HCV//HCV/RNA (NAT/PCR)
			3-Pre-Donation Clinical Information	EBV Total
			3-Pre-Donation Clinical Information	EBV//IgG
			3-Pre-Donation Clinical Information	EBV//IgM
			3-Pre-Donation Clinical Information	Pre-Donation//Height
			3-Pre-Donation Clinical Information	Pre-Donation Height//Status
			3-Pre-Donation Clinical Information	Pre-Donation//Weight
			3-Pre-Donation Clinical Information	Pre-Donation Weight//Status
			3-Pre-Donation Clinical Information	History of Cancer
			3-Pre-Donation Clinical Information	History of Cancer Specify//Specify	Value or status is reported, not both
			3-Pre-Donation Clinical Information	Cancer Free Interval
			3-Pre-Donation Clinical Information	Cancer Free Interval //Status	Value or status is reported, not both
			4-Pre_Donation Clinical Information	History of Cigarette Use
			4-Pre_Donation Clinical Information	History of Cigarette Use Pack Years//If Yes, Check # pack years
			4-Pre_Donation Clinical Information	Duration of Abstinence
			4-Pre_Donation Clinical Information	Other Tobacco Used	Value or status is reported, not both
			4-Pre-Donation Liver Clinical Information	Total Bilirubin
			4-Pre-Donation Liver Clinical Information	Total Bilirubin//Status
			4-Pre-Donation Liver Clinical Information	SGOT/AST
			4-Pre-Donation Liver Clinical Information	SGOT/AST//Status
			4-Pre-Donation Liver Clinical Information	SGPT/ALT
			4-Pre-Donation Liver Clinical Information	SGPT/ALT//Status	Value or status is reported, not both
			4-Pre-Donation Liver Clinical Information	Alkaline Phosphatase
			4-Pre-Donation Liver Clinical Information	Alkaline Phosphatase//Status	Value or status is reported, not both
			4-Pre-Donation Liver Clinical Information	Serum Albumin
			4-Pre-Donation Liver Clinical Information	Serum Albumin//Status	Value or status is reported, not both
			4-Pre-Donation Liver Clinical Information	Serum Creatinine
			4-Pre-Donation Liver Clinical Information	Serum Creatinine//Status	Value or status is reported, not both
			4-Pre-Donation Liver Clinical Information	INR
			4-Pre-Donation Liver Clinical Information	INR//Status	Value or status is reported, not both
			4-Pre-Donation Liver Clinical Information	Liver Biopsy
			4-Pre-Donation Liver Clinical Information	% Macro/intermediate vesicular fat //Status	Value or status is reported, not both
			4-Pre-Donation Liver Clinical Information	% Micro/intermediate vesicular fat //Status
			3-Pre-Donation Kidney Clinical Information	History of Hypertension
			3-Pre-Donation Kidney Clinical Information	History of Hypertension Diet
			3-Pre-Donation Kidney Clinical Information	History of Hypertension Diuretics	Display Only - Cascades from Database
			3-Pre-Donation Kidney Clinical Information	History of Hypertension Other Hypertensive Medication
			3-Pre-Donation Kidney Clinical Information	Diabetes
			3-Pre-Donation Kidney Clinical Information	Diabetes Treatment
			3-Pre-Donation Kidney Clinical Information	Kidney Preoperative Creatinine//Serum Creatinine
			3-Pre-Donation Kidney Clinical Information	Kidney Preoperative Creatinine//Status
			3-Pre-Donation Kidney Clinical Information	Preoperative Blood Pressure Systolic
			3-Pre-Donation Kidney Clinical Information	Preoperative Blood Pressure Systolic//Status
			3-Pre-Donation Kidney Clinical Information	Preoperative Blood Pressure Diastolic
			3-Pre-Donation Kidney Clinical Information	Preoperative Blood Pressure Diastolic//Status	Value or status is reported, not both
			3-Pre-Donation Kidney Clinical Information	Urinalysis	Display Only
			3-Pre-Donation Kidney Clinical Information	Preoperative Urinalysis//Urine Protein	Value or status is reported, not both
			3-Pre-Donation Kidney Clinical Information	Preoperative Urinalysis//Protein-Creatinine Ratio
			3-Pre-Donation Lung Clinical Information	Diabetes
			3-Pre-Donation Lung Clinical Information	Diabetes Treatment
			5-Pre-Donation lung Clinical Information	FVC % predicted before//FVC % predicted	Value or status is reported, not both
			5-Pre-Donation lung Clinical Information	FVC % predicted before//Status
			5-Pre-Donation lung Clinical Information	FVC % predicted after//FVC % predicted	Value or status is reported, not both
			5-Pre-Donation lung Clinical Information	FVC % predicted after//Status	Value or status is reported, not both
			5-Pre-Donation lung Clinical Information	FEV1 % predicted before//FEV1 % predicted
			5-Pre-Donation lung Clinical Information	FEV1 % predicted before//Status	Value or status is reported, not both
			5-Pre-Donation lung Clinical Information	FEV1 % predicted after//FEV1 % predicted
			5-Pre-Donation lung Clinical Information	FEV1 % predicted after//Status	Value or status is reported, not both
			5-Pre-Donation lung Clinical Information	FEF (25-75%) % predicted before//FEF (25-75%) % predicted
			5-Pre-Donation lung Clinical Information	FEF (25-75%) % predicted before//Status	Value or status is reported, not both
			5-Pre-Donation lung Clinical Information	FEF (25-75%) % predicted after//FEF (25-75%) % predicted
			5-Pre-Donation lung Clinical Information	FEF (25-75%) % predicted after//Status	Value or status is reported, not both
			5-Pre-Donation lung Clinical Information	TLC % predicted before//TLC % predicted
			5-Pre-Donation lung Clinical Information	TLC % predicted before//Status	Value or status is reported, not both
			5-Pre-Donation lung Clinical Information	TLC % predicted after//TLC % predicted
			5-Pre-Donation lung Clinical Information	TLC % predicted after//Status	Value or status is reported, not both
			5-Pre-Donation lung Clinical Information	Diffusing lung capacity corrected for alveolar volume % predicted
			5-Pre-Donation lung Clinical Information	Diffusing lung capacity corrected for alveolar volume % predicted//Status	Value or status is reported, not both
			5-Pre-Donation lung Clinical Information	PaO2 on room air
			5-Pre-Donation lung Clinical Information	PaO2 on room air//Status	Value or status is reported, not both
			Liver Surgical Information	Type of Transplant Graft
			Kidney Surgical Information	Kidney//Type of Transplant Graft	Display Only - Cascades from Database
			Kidney Surgical Information	Kidney//Intended Procedure Type	Value or status is reported, not both
			Kidney Surgical Information	Conversion from Laparoscopic to Open
			Lung Surgical Information	Lung//Type of Transplant Graft	Display Only - Cascades from Database
			Lung Surgical Information	Lung//Procedure Type	Value or status is reported, not both
			Lung Surgical Information	Conversion from Thoracoscopic to Open
			Lung Surgical Information	Intra-operative Complications
			Lung Surgical Information	Intra-operative Complications Specify//If Yes, Specify
			Lung Surgical Information	Sacrifice of Second Lobe, Specify
			Lung Surgical Information	Anesthetic Complication Specify
			Lung Surgical Information	Arrhythmia requiring therapy
			Lung Surgical Information	Intra-operative Complications Other//Other Specify
			6-Post-Operative Information	Date of Initial Discharge
			6-Post-Operative Information	Donor Status
			6-Post-Operative Information	Date Last Seen or Death
			6-Post-Operative Information	Cause of Death
			6-Post-Operative Information	Cause of Death//Other Specify
			6-Post-Operative Information	Non-Autologous Blood Administration
			6-Post-Operative Information	PRBC Units//If Yes, Number of Units
			6-Post-Operative Information	Platelets Units//If Yes, Number of Units
			6-Post-Operative Information	FF Units//If Yes, Number of Units
			8-Liver Related Post-Operative Complications	Biliary Complications
			8-Liver Related Post-Operative Complications	Biliary Complications//If Yes, Specify
			8-Liver Related Post-Operative Complications	Biliary Complications//If Yes, Specify://Date of surgery
			8-Liver Related Post-Operative Complications	Liver Vascular Complications Requiring Intervention//Vascular Complications Requiring Intervention
			8-Liver Related Post-Operative Complications	Liver Vascular Complications//If Yes, Specify
			8-Liver Related Post-Operative Complications	Liver Vascular Complications Other//Specify
			8-Liver Related Post-Operative Complications	Liver Other Complications Requiring Intervention
			8-Liver Related Post-Operative Complications	Liver Other Complications//If Yes, Specify
			8-Liver Related Post-Operative Complications	Liver Other Complications Other//Specify
			8-Liver Related Post-Operative Complications	Liver Reoperation
			8-Liver Related Post-Operative Complications	Reoperation//If yes, specify reason for reoperation (during first six weeks)
			8-Liver Related Post-Operative Complications	Liver Reoperation Liver Failure
			8-Liver Related Post-Operative Complications	Liver Reoperation Liver Failure Date
			8-Liver Related Post-Operative Complications	Liver Reoperation Bleeding Complications
			8-Liver Related Post-Operative Complications	Liver Reoperation Bleeding Date//Date
			8-Liver Related Post-Operative Complications	Liver Reoperation Hernia Repair
			8-Liver Related Post-Operative Complications	Liver Reoperation Hernia Repair Date
			8-Liver Related Post-Operative Complications	Liver Reoperation Bowel Obstruction
			8-Liver Related Post-Operative Complications	Liver Reoperation Bowel Obstruction Date
			8-Liver Related Post-Operative Complications	Liver Reoperation Vascular Complications
			8-Liver Related Post-Operative Complications	Liver Reoperation Vascular Date
			8-Liver Related Post-Operative Complications	Liver Reoperation Other//Other Specify
			8-Liver Related Post-Operative Complications	Liver Reoperation Other Specify//Other Specify
			8-Liver Related Post-Operative Complications	Liver Reoperation Other Date
			8-Liver Related Post-Operative Complications	Liver Readmission//Any Readmission After Initial Discharge
			8-Liver Related Post-Operative Complications	Liver Readmission Reason//If yes, specify reason for readmission (during first six weeks)
			8-Liver Related Post-Operative Complications	Liver Readmission Reason Other//Other Specify
			8-Liver Related Post-Operative Complications	Liver Readmission Date//If Yes, Date of First Readmission
			8-Liver Related Post-Operative Complications	Liver Other Interventional Procedures
			8-Liver Related Post-Operative Complications	Liver Other Interventional Procedures//If Yes, Specify Procedure
			8-Liver Related Post-Operative Complications	Liver Other Interventional Procedures Date//Date of Procedure
			7-Kidney Related Post-Operative Complications	Kidney Vascular Complications Requiring Intervention//Vascular Complications Requiring Intervention
			7-Kidney Related Post-Operative Complications	Kidney Vascular Complications//If Yes, Specify
			7-Kidney Related Post-Operative Complications	Kidney Vascular Complications Other//Specify
			7-Kidney Related Post-Operative Complications	Kidney Other Complications Requiring Intervention//Other Complications Requiring Intervention
			7-Kidney Related Post-Operative Complications	Kidney Other Complications//If Yes, Specify
			7-Kidney Related Post-Operative Complications	Kidney Other Complications Other//Other Specify
			7-Kidney Related Post-Operative Complications	Kidney Reoperation//Reoperation
			7-Kidney Related Post-Operative Complications	Reoperation//If yes, specify reason for reoperation (during first six weeks)
			7-Kidney Related Post-Operative Complications	Kidney Reoperation Bleeding//Bleeding
			7-Kidney Related Post-Operative Complications	Kidney Reoperation Bleeding Date//Date
			7-Kidney Related Post-Operative Complications	Kidney Reoperation Hernia Repair//Hernia Repair
			7-Kidney Related Post-Operative Complications	Kidney Reoperation Hernia Repair Date//Date
			7-Kidney Related Post-Operative Complications	Kidney Reoperation Bowel Obstruction//Bowel Obstruction
			7-Kidney Related Post-Operative Complications	Kidney Reoperation Bowel Obstruction Date//Date
			7-Kidney Related Post-Operative Complications	Kidney Reoperation Vascular//Vascular
			7-Kidney Related Post-Operative Complications	Kidney Reoperation Vascular Date//Date
			7-Kidney Related Post-Operative Complications	Kidney Reoperation Other//Other Specify
			7-Kidney Related Post-Operative Complications	Kidney Reoperation Other Specify//Other Specify
			7-Kidney Related Post-Operative Complications	Kidney Reoperation Other Date//Date
			7-Kidney Related Post-Operative Complications	Kidney Readmission//Any Readmission After Initial Discharge
			7-Kidney Related Post-Operative Complications	Kidney Readmission Reason//If yes, specify reason for readmission (during first six weeks)
			7-Kidney Related Post-Operative Complications	Kidney Readmission Reason Other//Other Specify
			7-Kidney Related Post-Operative Complications	Kidney Readmission Date//If Yes, Date of First Readmission
			7-Kidney Related Post-Operative Complications	Kidney Other Interventional Procedures//Other Interventional Procedures
			7-Kidney Related Post-Operative Complications	Kidney Other Interventional Procedures//If Yes, Specify Procedure
			7-Kidney Related Post-Operative Complications	Kidney Other Interventional Procedures Date//Date of Procedure
			8-Liver Related Post-Operative Complications	Lung Readmission Reason Other//Specify
			9-Lung Related Post-Operative Complications	Post-operative complications during the initial hospitalization
			9-Lung Related Post-Operative Complications	Post-operative Complications//If Yes, Specify
			9-Lung Related Post-Operative Complications	Arrhythmia requiring therapy
			9-Lung Related Post-Operative Complications	Placement of Additional Thoracostomy Tube(s), Indication
			9-Lung Related Post-Operative Complications	Post-operative Complications Other//Other Specify
			9-Lung Related Post-Operative Complications	Lung Readmission//Any Readmission After Initial Discharge
			9-Lung Related Post-Operative Complications	Lung Readmission Reason//If yes, specify reason for readmission (during first six weeks)
			8-Liver Related Post-Operative Complications	Lung Readmission Reason Other//Specify
			9-Lung Related Post-Operative Complications	Lung Readmission Date//If Yes, Date of First Readmission
			10-Post-Operative Clinical Information	Most Recent Date of Tests
			10-Post-Operative Clinical Information	Weight in Lb
			10-Post-Operative Clinical Information	Kidney Serum Creatinine
			10-Post-Operative Clinical Information	Kidney Serum Creatinine//Status
			10-Post-Operative Clinical Information	Post-Op Blood Pressure Systolic
			10-Post-Operative Clinical Information	Post-Op Blood Pressure Systolic//Status
			10-Post-Operative Clinical Information	Post-Op Blood Pressure Diastolic
			10-Post-Operative Clinical Information	Post-Op Blood Pressure Diastolic//Status	Value or status is reported, not both
			10-Post-Operative Clinical Information	Urinalysis	Display Only
			10-Post-Operative Clinical Information	Post-Operative Urinalysis//Urine Protein	Value or status is reported, not both
			10-Post-Operative Clinical Information	Post-Operative Urinalysis//Protein-Creatinine Ratio
			10-Post-Operative Clinical Information	Donor Developed Hypertension Requiring Medication
			10-Post-Operative Clinical Information	Total Bilirubin	Value or status is reported, not both
			10-Post-Operative Clinical Information	Total Bilirubin//Status
			10-Post-Operative Clinical Information	SGOT/AST
			10-Post-Operative Clinical Information	SGOT/AST//Status
			10-Post-Operative Clinical Information	SGPT/ALT
			10-Post-Operative Clinical Information	SGPT/ALT//Status	Value or status is reported, not both
			10-Post-Operative Clinical Information	Alkaline Phosphatase
			10-Post-Operative Clinical Information	Alkaline Phosphatase//Status	Value or status is reported, not both
			10-Post-Operative Clinical Information	Serum Albumin
			10-Post-Operative Clinical Information	Serum Albumin//Status	Value or status is reported, not both
			10-Post-Operative Clinical Information	Serum Creatinine
			10-Post-Operative Clinical Information	Serum Creatinine//Status	Value or status is reported, not both
			10-Post-Operative Clinical Information	INR
			10-Post-Operative Clinical Information	INR//Status	Value or status is reported, not both
			10-Post-Operative Clinical Information	Post-Operative//Weight
			10-Post-Operative Clinical Information	Post-Operative Weight//Status	Value or status is reported, not both
			10-Post-Operative Clinical Information	Organ Recovery Date
			10-Post-Operative Clinical Information	Organ(s) Recovered	Value or status is reported, not both
			10-Post-Operative Clinical Information	Recipient Last Name
			10-Post-Operative Clinical Information	Recipient First Name	Value or status is reported, not both
			10-Post-Operative Clinical Information	Recipient SSN#
			10-Post-Operative Clinical Information	Donor Recovery Facility Center Code//Donor Recovery Facility	Display Only - Cascades from Database
			10-Post-Operative Clinical Information	Donor Recovery Facility Center Type	Display Only - Cascades from Database
			10-Post-Operative Clinical Information	Donor Workup Facility Center Code	Display Only - Cascades from Database
			10-Post-Operative Clinical Information	Donor Workup Facility Center Type	Display Only - Cascades from Database
				Public Burden Statement